Clinical Decisionmaking

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It has been standard practice to remove lymph nodes in the armpit (axillary) during mastectomy (removal of the entire breast) or after lumpectomy to find out if the cancer has spread to the lymph nodes. This usually requires a 4 to 6 inch incision, removal of 10 to 30 lymph nodes, and insertion of a drainage tube.

Although this lymph node surgery creates arm pain and function problems for some women, which in turn can affect mental outlook, it does not lessen fears about cancer recurrence, according to a new study. This suggests that the risks may outweigh the potential benefits of axillary lymph node dissection for these women, concludes lead author, Jeanne S. Mandelblatt, M.D., M.P.H., of Georgetown University.

In the study supported in part by the Agency for Healthcare Research and Quality (HS08395), Dr. Mandelblatt and her colleagues examined the quality of life of 571 elderly women who were diagnosed with stage 1 and 2 breast cancer between 1995 and 1997 from 29 hospitals in five regions. They interviewed the women 3 months after surgery and again 12 and 24 months after surgery. They asked the women about problems with arm functioning (for example, chronic swelling or loss of arm movement), physical and mental functioning, overall impact of breast cancer on their lives, and worry about cancer recurrence.

Sixty percent of women reported arm problems at some time in the 2 years after surgery (83 percent of those who underwent axillary surgery and 17 percent who did not). Women who reported arm problems in the 2 years after surgery also reported using significantly more physical therapy services (22 vs. 6 percent) and received slightly more family help (23 vs. 17 percent) than women without arm problems. Arm problems also were the primary determinant of reduced physical and mental functioning, after controlling for other factors. The authors conclude that the role of axillary surgery should be reexamined in older women. They may benefit from newer sentinel lymph node biopsy of only a few nodes, which is associated with less pain and fewer complications.